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COUNTY OF SAN JOAQUIN Date: z <br /> DEPARTMENT OF PULIC WORKS <br /> Received By: 5a- <br /> DRIVEWAYS AND PAVED FRONTAGES <br /> PERMIT APPLICATION CR#: 04L379 <br /> APPLICANT OFFICE USE ONLY <br /> Name: mlct. A t2&Vh' ,0 <br /> Address: 4vf' JOB#: 11005 ISSUE DATE: <br /> City,State,Zip Code: c r, cA . Q 3: APN 0,97—/9 �p FEE DUE: <br /> Area Code -Telephone Number:"20 q I I y 5 #-- EXP.DATE: DRIVEWAYS: <br /> STREET: <br /> SITE INFORMATION: AREA: cam,-�-,�G� QUAD Ate-- <br /> Parcel <br /> te=Parcel Owner's Name: TYPE: , <br /> Site Address: ,At M Ems- 4 - FORMS: ,rd /7 <br /> City,State,Zip Code: NOTES: <br /> Area Code -Telephone Number o q <br /> DRIVEWAY <br /> CONTRACTOR TYPE: QUANTITY WIDTHS <br /> Name: AGRICULTURE: @FRONTAGE <br /> Address: COMMERCIAL: <br /> City, State,Zip Code: INDUSTRIAL: @ R/W <br /> Area Code -Telephone Number: RESIDENCE: <br /> PAVED FRONTAGE <br /> LENGTH: Ft. X WIDTH: Ft. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise enc oach on County H' ay Right-of-Way on the <br /> -�z,-7?V side of f1G 6e /'�/�: approximately :3d fe <br /> of �/�� S��i�N� � by installing �7:3 <br /> Work will <br /> commence on or about for approximately days. <br /> SKETCH(Separate sheet may be submitted) <br /> Will this project be self-installed? YES NO Contractor's License <br /> 11SJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKWIASTER.PS%ENCROACHMENT PERMIT DRIVEWAY.DOC (10/09) Page 1 of 2 <br />